by Ripal T. Gandhi, MD, and Suvranu Ganguli, MD
Renal artery stent outcomes: Effect of baseline blood pressure, stenosis severity and translesion pressure gradient.
J Am Coll Cardiol. 2015 Dec 8;66(22):2487-94. doi: 10.1016/j. jacc.2015.09.073.
Murphy TP, Cooper CJ, Matsumoto AH, Cutlip DE, Pencina KM, Jamerson K, Tuttle KR, Shapiro JI, D’Agostino R, Massaro J, Henrich W, Dworkin LD.
BACKGROUND: Multiple randomized clinical trials comparing renal artery stent placement plus medical therapy with medical therapy alone have not shown any benefit of stent placement. However, debate continues whether patients with extreme pressure gradients, stenosis severity, or baseline blood pressure benefit from stent revascularization.
OBJECTIVES: The study sought to test the hypothesis that pressure gradients, stenosis severity, and/or baseline blood pressure affects outcomes after renal artery stent placement.
METHODS: Using data from 947 patients with a history of hypertension or chronic kidney disease from the largest randomized trial of renal artery stent placement, the CORAL (Cardiovascular Outcomes in Renal Atherosclerotic Lesions) study, we performed exploratory analyses to determine if subsets of patients experienced better outcomes after stent placement than the overall cohort. We examined baseline stenosis severity, systolic blood pressure and translesion pressure gradient (peak systolic and mean) and performed interaction tests and Cox proportional hazards analyses for the occurrence of the primary endpoint through all follow-up, to examine the effect of these variables on outcomes by treatment group.
RESULTS: There were no statistically significant differences in outcomes based on the examined variables nor were there any consistent nonsignificant trends.
CONCLUSIONS: Based on data from the CORAL randomized trial, there is no evidence of a significant treatment effect of the renal artery stent procedure compared with medical therapy alone based on stenosis severity, level of systolic blood pressure elevation, or according to the magnitude of the trans-stenotic pressure gradient. (Benefits of Medical Therapy Plus Stenting for Renal Atherosclerotic Lesions [CORAL]; NCT00081731).
Contemporary outcomes of open and endovascular popliteal artery aneurysm repair.
J Vasc Surg. 2016 Jan;63(1):70-6. doi: 10.1016/j. jvs.2015.08.056. Epub 2015 Oct 21.
Leake AE, Avgerinos ED, Chaer RA, Singh MJ, Makaroun MS, Marone LK.
OBJECTIVE: The purpose of this study was to evaluate contemporary practice and outcomes of open repair (OR) or endovascular repair (ER) for popliteal artery aneurysms (PAAs).
METHODS: Consecutive patients with PAA treated at one institution from January 2006 to March 2014 were reviewed under an Institutional Review Board–approved protocol. Demographics, indications, anatomic characteristics and outcomes were collected. Standard statistical methods were used.
RESULTS: A total of 186 PAAs were repaired in 156 patients (110 ORs, 76 ERs) with a mean age of 71 ± 11 years and most were male (96 percent). Mean follow-up was 34.9 ± 28.6 months for OR and 28.3 ± 25.8 months for ER (P = .12). Comorbidities were similar between groups. OR was used in more patients with PAA thrombosis (41.8 percent vs. 5.3 percent; P < .001), acute ischemia (24.5 percent vs. 9.2 percent; P = .010) and ischemic rest pain (34.5 percent vs. 6.6 percent; P < .001). Mean tibial (Society for Vascular Surgery) runoff score was 5.0 for OR vs. 3.3 for ER (P = .006). OR was associated with increased 30-day complications (22 percent vs. 2.6 percent; P < .001) and mean postoperative stay (5.8 vs. 1.6 days; P < .001). There was no difference in 30-day mortality (OR, 1.8 percent; ER, 0 percent; P = .56) or major amputation rate (OR, 3.7 percent; ER, 1.3 percent; P = .65). Primary, primary assisted and secondary patency rates were similar at 3 years (OR, 79.5 percent, 83.7 percent, and 85 percent; ER, 73.2 percent, 76.3 percent, and 83 percent; P = NS). Among 130 patients presenting electively without acute ischemia or thrombosed PAA (63 ORs and 67 ERs), OR had better 3-year primary patency (88.3 percent vs. 69.8 percent; P = .030) and primary assisted patency (90.2 percent vs. 73.5 percent; P = .051) but similar secondary patency (90.2 percent vs. 82 percent; P = .260). ER thrombosis was noted in 8 of 24 patients treated in 2006–2008 (33 percent; mean time to failure, 49 months) but in only 4 of 51 patients treated in 2009–2013 (7.8 percent; mean time to failure, 30 months), suggesting a steep learning curve.
CONCLUSIONS: ER is a safe and durable option for PAA, with lower complication rates and a shorter length of stay. OR has superior primary patency in patients treated electively but no difference in midterm secondary patency and amputations.
SPRING 2016 | IR QUARTERLY 33
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